Adult Health Med Surg Nursing Test Banks

Correct Answer: A

Rationale: Turning and repositioning the patient every 2 hours is the most effective nursing intervention in preventing pressure ulcers in a patient with a history of stroke and immobility. Pressure ulcers, also known as bedsores, are caused by prolonged pressure on the skin, leading to reduced blood flow and tissue damage. By regularly turning and repositioning the patient, pressure is relieved from specific areas of the body, helping to prevent the development of pressure ulcers. This intervention helps to redistribute pressure, improve blood flow, and reduce the risk of skin breakdown, thus promoting skin integrity in immobile patients.

Correct Answer: B

Rationale: When managing a conscious patient with a foreign object lodged in the eye, the appropriate action is to rinse the eye with sterile saline solution. This helps to flush out the foreign object and reduce the risk of further injury or infection. Attempting to remove the object with tweezers or applying pressure to the eyelid can potentially cause more harm to the eye. Placing a bandage over the affected eye is not beneficial in this situation as it does not address the presence of the foreign object. Rinsing the eye with sterile saline solution is the safest and most effective initial step to take in managing a foreign object lodged in the eye.

Correct Answer: C

Rationale: Benzodiazepines are commonly prescribed for the management of insomnia due to their sedative effects. One of the most common adverse effects of benzodiazepines is daytime drowsiness, which can impair the patient's ability to function normally during the day. Monitoring the patient closely for daytime drowsiness is important to ensure their safety and well-being, as it can affect their daily activities and increase the risk of accidents or falls. It is essential for the nurse to educate the patient on the potential for daytime drowsiness and advise them to avoid activities that require full alertness, such as driving or operating heavy machinery, until they know how the medication affects them. If the patient experiences severe or persistent daytime drowsiness, the healthcare provider may need to adjust the dosage or consider alternative treatment options.

Correct Answer: A

Rationale: Grounded theory is a qualitative research method that focuses on generating theory from data rather than testing pre-existing theories. In this scenario, where the goal is to explore social processes observed in the delivery room activities, grounded theory would be the most appropriate method. This method allows researchers to systematically collect and analyze data in order to develop theoretical explanations for social phenomena. By using grounded theory, researchers can explore the interactions, behaviors, and social processes at play in the delivery room in a structured and systematic way, thereby gaining insights into these phenomena through an inductive approach.

Correct Answer: B

Rationale: The importance of validation in the context of communication and nursing care does not include the assumption that most patients are cognitively impaired. It would be more appropriate to approach patient interactions with the assumption that patients are capable of understanding and coherent communication. Validation is important because it helps ensure that the nurse has truly understood the patient's message, prevents misinterpretation, and fosters a sense of empathy and trust in the nurse-patient relationship. Additionally, validating the patient's thoughts and feelings can help clarify confused thoughts and promote effective communication. The other options (A, C, and D) are all valid reasons emphasizing the significance of validation in effective communication.